What does it mean when the country with the largest HIV epidemic in the world sees prevalence of the virus rise? In South Africa, one of the last countries in Africa to make treatment available to those who needed it and now home to the largest antiretroviral treatment program on earth, it means that more people are living with the virus longer while overall rates of new infections remain stable. After that, according to the South African National HIV Prevalence, Incidence and Behavior Survey, 2012, it gets complicated. The survey, the fourth in a series of HIV household surveys that began in 2002 finds troubling trends in the rates of new infections as well as in behaviors and beliefs, that prompt study authors to conjecture “that the beneficial impact of increased antiretroviral treatment coverage on HIV incidence (through viral load reduction in HIV-positive individuals) has been more than offset by the disturbing trends of increased HIV-risk behaviour in the country . . .”

As the report notes, the survey’s findings, which point to a continued inequitable distribution of rates of new infections — between young women and young men, between dwellers of “formal” versus “informal” urban areas, and highest among young black women — will make the national strategic plan’s primary goal of halving new infections between 2012 and 2016 “extremely difficult to attain.” The role the authors attribute to “behaviour,” (used as a euphemism for “sex,”) as well as their recommended responses to the likely upcoming failure to halve incidence, however, may be limited by the survey’s scope. The survey, which queried respondents on age of first sexual experience, age differences between teenaged sex partners, multiple sexual partners, and condom use, noted what authors call “concerning trends.” These included an increase of those reporting their first sexual experience occurred before the age of 15, a continued “steady increase” in teen-aged girls reporting having a more-than-five-years-older partner, and another steady increase in those who reported having more than one sexual partner in the preceding year. Those findings, along with reported drops in reported condom use (from the 2008 reported peak of 45.1 percent to the 2012 36.2 percent), and respondents’ reported unrealistic views of risks of acquiring the virus lead to the report’s recommendations. Some of these are things that should happen anyway, including, “It is recommended that SANAC [South African National AIDS Council] and its partners . . . design and roll out a comprehensive combination package of HIV prevention and treatment interventions that are targeted at residents of informal settlements. Together with other government departments, SANAC should seek to reduce the poor housing conditions, poverty, and unemployment that characterise informal settlement areas and create an HIV risk environment.”

Other recommendations, however seem less supported by the findings of the survey, which was funded by USAID, the Bill and Melinda Gates Foundation, the Human Sciences and Research Council and the South African National AIDS Council. These include: “Age-disparate relationships are considered a major behavioural risk factor for HIV infection among young females; hence the urgent need to discourage this behavior. This can be achieved through the design of targeted SBCC interventions for young females to raise awareness about the risk of such relationships.” Another recommendation, “It is necessary to revive the health promotion campaign to educate the public even about the basic message of ‘Abstain, Be faithful, Condomise’ (or simply ABC) to equip the population with basic knowledge about HIV prevention as was done during the pre-ART [antiretroviral treatment] era,” takes a similar leap. While the report on the survey acknowledges the debt of some of the successes it reports — notably, increased survival rates — to evidence-based methods, neither of the campaigns suggested in the two recommendations above meets the qualification of being evidence-based. In fact, the findings of the report would seem to suggest that they have not been effective interventions when previously — and recently — employed.

Studies presented at the recent Conference on Retroviruses and Opportunistic Infections on the role of so-called “sugar daddies” or older male partners, and multiple concurrent sex partners in HIV epidemics, as well as earlier studies, have indicated that these campaigns are missing their target, if their target is lowering numbers of new infections. While the recommendations are limited by the scope of the study, which did not gather data on treatment disruptions (or the resulting impact on viral suppression), the gains in treatment access and survival the survey does show would seem to make the greatest priority a continued effort to make those gains equally accessible to everyone who has the virus. The study shows one area where doing that might help to address discrepant rates of new infections when it notes that, “a significantly greater proportion of females (34.7%) than males (25.7%) had accessed treatment.” One result of that could be that a man who has sex with women has a greater chance that, if his partner has HIV, she is viraly suppressed, than a woman has of her HIV positive male partner being viraly suppressed. And that in turn could go some way toward explaining the higher rates of new infections among young women than young men. Working to equalize treatment access could pay off more immediately than new billboards.

The authors note “HIV incidence measures are important because they provide insights into the more recent dynamics of the country’s HIV epidemic. More importantly, they are the most direct means of assessing the impact of HIV-prevention programmes that the country has implemented.” What the authors don’t add, is that HIV incidence measures may also point to the need to gather more information about the success of making treatment accessible and continuable to all who need it.

The science is clear, HIV criminalization is abusive, discriminatory and counterproductive – The destructiveness of HIV-specific laws that fueled stigma and discouraged diagnosis by criminalizing people […]